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REV-788 BA 11-03 BOARD OF APPEALS DEPT. 281021 HARRISBURG PA 17128-1021 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE PENNSYLVANIA evenue CORPORATE OFFICER SIGNATURE FORM BOA DOCKET NUMBER S PETITIONER NAME AND ADDRESS NAME ADDRESS CITY STATE ZIP TAX IDENTIFICATION NUMBER PA BOX NUMBER TAX TYPE TAX PERIOD AUTHORIZED REPRESENTATIVE BUSINESS NAME REPRESENTATIVE CONTACT PERSON LAST NAME FIRST NAME MIDDLE INITIAL Under penalties prescribed by law I hereby certify that the above referenced...
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